Family physicians who have grown comfortable with ATP III's "treat to target" paradigm for cholesterol management were likely surprised by the new guideline's "fire and forget" approach, which advises prescribing fixed doses of statins based on cardiovascular risk assessments and not routinely rechecking cholesterol levels. The latter approach is more consistent with the evidence from randomized controlled trials, but this change is, nonetheless, a significant reversal of an established medical practice. Although such reversals are surprisingly common, they can be unsettling to clinicians.

In an editorial in the December 1st issue of American Family Physician, Drs. Caroline Wellbery and Rebecca McAteer review reasons for other dramatic reversals such as hormone replacement therapy and tight glucose control in diabetes, which include poor design and small size; focus on disease-oriented evidence, application of findings to nonstudy populations; unidentified harms; and economic factors. They have several related suggestions to help physicians avoid pitfalls associated with currently accepted practices that may be vulnerable to later reversal:

To minimize the dizzying impact of changing recommendations, physicians should focus on patient-oriented evidence, and not be distracted by disease-oriented evidence. Physicians should become familiar with the basic principles of good research, and avoid drawing premature conclusions from observational studies or studies with design flaws. Physicians should also recognize the pharmaceutical industry's influence on research studies and practice recommendations.
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1 comment:

I expect that this is going to be a hard sell to both physicians and patients. When the idea of treat and not retest was discussed with a couple of patients this week they were simply incredulous and not at all interested in this approach. Change is hard, especially when it just seems non-intuitive. The patients I've discussed this with suspect it is a "cost saving" government recommendation.

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About Me

I am a board-certified Family Physician and Public Health professional practicing in the Washington, DC area. I am also Deputy Editor of the journal American Family Physician and teach family and preventive medicine and population health at Georgetown University School of Medicine, Uniformed Services University of the Health Sciences, and Johns Hopkins University Bloomberg School of Public Health.
I am paid to provide independent editorial and medical consulting services to the American Academy of Family Physicians, John Wiley & Sons, BHS, and WebMD. However, the content of this blog reflects my personal views only, and does not represent the views of any academic institution, publisher, BHS, or the AAFP.